HMO High Deductible Certificate of Coverage - thcmi.com€¦ · NONDISCRIMINATION NOTICE Total...

HMO High DeductibleCertificate of Coverage

2018

Table of Contents

NONDISCRIMINATION NOTICE i

ARTICLE I TOTAL HEALTH CARE USA INC 1

ARTICLE II DEFINITIONS 1ndash6

ARTICLE III ENROLLMENT EFFECTIVE DATE OF COVERAGE PREMIUMS 6ndash8

ARTICLE IV GENERAL CONDITIONS 8ndash14

ARTICLE V COVERED BENEFITS AND SERVICES 14ndash34

ARTICLE VI EXCLUSIONS AND LIMITATIONS 35ndash36

ARTICLE VII PRIOR APPROVALAUTHORIZATION REQUIREMENTS 37ndash38

ARTICLE VIII SUBROGATION 38

ARTICLE IX COORDINATION OF BENEFITS 39ndash40

ARTICLE X CHANGES IN RATES CERTIFICATE OR STATUS OF MEMBERS 40

ARTICLE XI TERMINATION OF GROUP COVERAGE 41

ARTICLE XII TERMINATION OF A MEMBERrsquoS COVERAGE 41ndash42

ARTICLE XIII CONTINUATION COVERAGE AND CONVERSION 42ndash43

ARTICLE XIV MEMBERS RIGHTS amp RESPONSIBILITIES 43ndash44

ARTICLE XV PRESCRIPTION DRUG RIDER 44ndash45

THC3060D_Large Group HDHP HMO 2018

NONDISCRIMINATION NOTICE

Total Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Total Health Care does not exclude people or treat them differently because of race color national origin age disability or sex

Total Health Care

bull Provides free aids and services to people with disabilities to communicate effectively with us such as ndash Qualified sign language interpreters ndash Written information in other formats (large print audio accessible electronic formats other formats)

bull Provides free (no cost) language services to people whose primary language is not English such as ndash Qualified interpreters ndash Information written in other languages

If you need these services contact Total Health Care at (800) 826-2862 24 hours a day seven days a week TTY users call 711

If you believe that Total Health Care has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with

bull Total Health Care Civil Rights Coordinator 3011 W Grand Blvd Suite 1600 Detroit MI 48202 (800) 826-2862 (TDDTTY 711) Fax (800) 826-6406 or email thcthcmicom

bull You can file a grievance by mail fax or email If you need help filing a grievance Total Health Care Customer Service is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at ocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201

(800) 368-1019 (800) 537-7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

i

2

Arabic

(رقم--1ملحوظة إذا كنت تتحدث اللغة العربیة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

826-2862 (800) (TTY 711)ھاتف الصم والبكم

Chinese Mandarin 注意如果您说中文普通话国语我们可为您提供免费语言援助服务请致电(800) 286-2862 (TTY 711)

Chinese Cantonese 注意如果您使用粵語您可以免費獲得語言援助服務請致電 (800) 826-2862 (TTY 711)

Syriac

ܚܬܘܢ ܐܢ ܙܘܗܪܐ ܡܙܡܝܬܘܢ ܟܐ ܐ ܒܠܝܬܘܢ ܡܨܝܬܘܢ ܐܬܘܪܝܐ ܠܫܢܐ ܗ ܬܐ ܕܩ ܪܬܐ ܚܠܡ ܝ ܓܢܐܝܬ ܒܠܫܢܐ ܕܗ ܠ ܩܪܘܢ ܡ ܡܢܝܢܐ ܥ(800) 826-2862 (TTY 711)

Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số (800) 826-2862 (TTY 711)

Albanian KUJDES Neumlse flitni shqip peumlr ju ka neuml dispozicion sheumlrbime teuml asistenceumls gjuheumlsore pa pageseuml Telefononi neuml (800) 826-2862 (TTY 711)

Korean 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 (800) 826-2862 (TTY 711) 번으로 전화해 주십시오

Bengali লয করzwjনঃ যিদ আপিন বাংলা কথা বলেত পােরন তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল আেছ েফান

করzwjন ১ (800) 826-2862 (TTY 711)

Polish UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer (800) 826-2862 (TTY 711)

German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer (800) 826-2862 (TTY 711)

Italian ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero (800) 826-2862 (TTY 711)

Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます (800) 826-2862 (TTY 711)までお電話にてご連絡ください

Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните (800) 826-2862 (TTY 711)

Serbo-Croatian OBAVJEŠTENJE Ako govorite srpsko-hrvatski usluge jezičke pomoći dostupne su vam besplatno Nazovite (800) 826-2862 (TTY-711 Telefon za osobe sa oštećenim govorom ili sluhom)

Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa (800) 826-2862 (TTY 711)

21 2017

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Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017 2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017 2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

2

Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

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Arabic





Syriac






করzwjন ১ (800) 826-2862 (TTY 711)








21 2017

1

Nondiscrimination Notice


Total Health Care bull Provides free aids and services to people with disabilities to communicate effectively with us

such as o Qualified sign language interpreters

o Written information in other formats (large print audio accessible electronic formats other formats)

bull Provides free (no cost) language services to people whose primary language is not English such as

o Qualified interpreters

o Information written in other languages



o Total Health Care Civil Rights Coordinator 3011 W Grand Blvd Suite 1600 Detroit MI 48202 (800) 826-2862 (TDDTTY 711) Fax (800) 826-6406 or email thcthcmicom

o You can file a grievance by mail fax or email If you need help filing a grievance Total Health Care Customer Service is available to help you


US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 (800) 368-1019 (800) 537-7697 (TDD)


English ATTENTION If you speak English language assistance services at no cost are available to you Call (800) 826-2862 (TTY 711)

Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al (800) 826-2862 (TTY 711)

ii

1

ARTICLE I TOTAL HEALTH CARE USA INC

Total Health Care USA Inc is a nonprofit corporation organized and licensed under the laws of the State of Michigan with its address at 3011 W Grand Blvd Suite 1600 Detroit MI 48202-3000

ARTICLE II DEFINITIONS

When used in this Certificate of Coverage Agreement Riders the Group Operating Agreement the Enrollment Application signed by the Subscriber and the identification card (ID) issued to Members the following definitions apply

201 ldquoAdverse Benefit Determinationrdquo means any of the following a denial reduction termination or failure to provide or make payment (in whole or in part) for a benefit including any such denial reduction termination or failure to provide or make payment that is based on a determination of a participantrsquos or beneficiaryrsquos eligibility to participate in a plan as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate

202 ldquoAffiliated Facilityrdquo means any legally qualified and state-licensed intermediate care or skilled nursing facility or Hospice which has a contract with the Plan to provide services for Members

203 ldquoAffiliated Hospitalrdquo means any Hospital that has a contract with the Plan to provide Hospital services to Members

204 ldquoAffiliated Pharmacyrdquo means a Pharmacy that contracts with the pharmacy benefit manager as designated by Total Health Care USA Inc to provide Covered Services to Members Planrsquos network includes Pharmacies within the Planrsquos service areas as well as a national network of Pharmacies for out-of-area services Names of Participating Pharmacies can be found in the Provider Directory or on online at wwwTHCmicom

205 ldquoAffiliated PhysicianPCPrdquo means a primary care provider licensed to practice medicine (family practitioner general practitioner internist pediatrician nurse practitioner or a physician assistant) who has contracted with the Plan

206 ldquoAffiliated Providerrdquo means a health professional a Hospital licensed pharmacy or any other institution organization or person who has a contract with the Plan or an IPA to render one (1) or more health maintenance services to Members Affiliated Providers make up the ldquoIn Total Health Care USA Networkrdquo

207 ldquoAffiliated Psychiatristrdquo means an individual licensed to practice psychiatry and who has a contract with the Plan to provide services to Members

208 ldquoApproved Clinical Trialrdquo means a Phase I II III or IV clinical trial for the prevention detection or treatment of cancer or other life-threatening condition or disease (or other condition described in the Patient Protection and Affordable Care Act [PPACA] such as federally funded trials trials conducted under an investigational new drug application reviewed by the FDA or drug trial exempt from having an investigational new drug application)

2

209 ldquoApproved Drug Listrdquo means a list of both Generic and Preferred Brand Name Drugs including Specialty Drugs approved by Total Health Care USA Pharmacy and Therapeutics Committee for use by our Members Preferred Brand Name Drugs are usually Brand Name Drugs that have been on the market for a while or are commonly prescribed and have been selected based on their clinical effectiveness and safety Non-preferred Brand Name Drugs are usually the highest cost drugs in a given category that have lower-cost alternatives with equal or better clinical effectiveness

210 ldquoAuthorized Benefits and Servicesrdquo are those health care benefits and services available to Members under this Certificate when provided by health care providers authorized to provide such care under this Certificate and which follow evidence-based guidelines of but not necessarily limited to USPTF HRSA guidelines and the CDC

211 ldquoBreast Cancer Rehabilitative Servicesrdquo means a procedure intended to improve the results of or ameliorate the debilitating consequences of treatment of breast cancer delivered on an inpatient or outpatient basis including but not limited to reconstructive plastic surgery physical therapy and psychological and social support services

212 ldquoCertificaterdquo means this Certificate of Coverage Agreement and applicable Riders

213 ldquoClean Claimrdquo means a claim that is completed in the format specified by the Plan It may be processed without obtaining more information from the provider of the service or from a third party All claims must be generated by a computer or typed In addition a ldquoclean claimrdquo is one that does all of the followingbull Identifies the health professional or facility that provided service sufficiently to verify if

necessary affiliation status and includes any identifying numbersbull Sufficiently identifies the patient and Subscriberbull Lists the date and place of servicebull Is a claim for Covered Services provided to a Memberbull If necessary substantiates the medical necessity and appropriateness of the service

providedbull If prior authorization is required contains information sufficient to establish that prior

authorization was obtainedbull Identifies the service rendered using a generally accepted system of procedure or service

coding andbull Includes additional documentation based on services rendered as reasonably required by

Planbull Is billed within one year of the date of service

214 ldquoCoinsurancerdquo means the balance of the allowable amount that each Member must pay after the Plan has paid its percentage towards the allowed amount

215 ldquoContract Yearrdquo means the twelve (12) month period from the date that coverage was initially effective under this Certificate It also refers to each twelve (12) month period thereafter unless otherwise stated and agreed upon

3

216 ldquoCo-Payrdquo means a service-specific fixed-dollar amount each Member must pay at the time and Place Authorized Benefits and Services are rendered

217 ldquoDeductiblerdquo means the dollar amount a Member must satisfy in a Plan Year for Authorized Benefits and Services before being eligible for certain benefits to be payable by the Plan The Deductible is applied annually and is based upon the Plan Year Each Plan Year begins a new Deductible period

218 ldquoDependentrdquo means any of the following unless otherwise excluded by the Group Operating Agreement (1) The Spouse of a Subscriber (2) Child of the spouse or subscriber by birth legal adoption or legal guardianship who has not attained the age of twenty-six (26) and (3) who is not offered any health coverage by their employer A child need not be claimed as a Dependent on the federal income tax return of the Subscriber to qualify as a Dependent

219 ldquoEnrollment Applicationrdquo means the form approved by the Plan by which the Subscriber seeks to enroll one or more Members in the Plan

220 ldquoGeneric Drugrdquo means a prescription drug approved by the Food and Drug Administration (FDA) that is produced and distributed without patent protection and contains the same active ingredient as the Brand Name Drug

221 ldquoGrace Periodrdquo means the thirty (30) day period allowed for payment of the Premium immediately following the due date for the Premium

222 ldquoGrouprdquo means an employer group or organization that has executed the Group Operating Agreement on behalf of its employees or members

223 ldquoGroup Operating Agreementrdquo means the agreement entered into between the Plan and the Group through its authorized representative which outlines the criteria of eligibility of persons to be Members of the Group and which together with any agreement regarding new and rehired group employees the Certificate the Enrollment Application and the Member identification (ID) card constitutes the contract between the Plan the Group and the Member

224 ldquoHabilitative Servicesrdquo mean health care services that help a person retain learn or improve skills and functioning for daily living (eg therapy for a child who is not walking or talking at the expected age) These services are for people with disabilities in a variety of inpatient and or outpatient settings

225 ldquoHealth Centerrdquo means a health care facility that is operated by an Individual Practice Association

226 ldquoHospicerdquo means a licensed health care program to provide a coordinated set of services rendered at home or in outpatient or institutional settings for individuals suffering from a disease or condition with a terminal prognosis

227 ldquoHospitalrdquo means a state-licensed acute care facility that provides inpatient outpatient and emergency medical surgical or psychiatric diagnosis treatment and care of injured or acutely sick persons by or under the supervision of a staff of physicians and that continuously

4

provides twenty-four (24) hour-a-day nursing service by registered nurses and which is not other than incidentally a place for the treatment of pulmonary tuberculosis a place for the treatment of drug abuse a place for the treatment of alcoholism nor a nursing home

228 ldquoIndividual Practice Associationrdquo or ldquoIPArdquo means a partnership corporation association or other entity that has a contract with a Plan to provide and arrange for services to Members has as its primary objective the delivery or arrangement for the delivery of health care services and employs or has entered into written service agreements with health professionals a majority of whom are physicians

229 ldquoMaximum Out-of-Pocket Expenserdquo means the highest or total amount a Member is required to pay towards the cost of health care in a Plan Year Co-pays Coinsurance and Deductibles all are applied to Maximum Out-of-Pocket Expense for services rendered through Affiliated Physicians Provider and Psychiatrists Other than Emergency Medical Services costs incurred outside of the Affiliated network do not apply toward the Out-of-Pocket Maximum The Out of Pocket Maximum does not include any of the following and once the Maximum Out of Pocket Expense has been reached you still will be required to pay any charges for non-covered health services and charges that exceed eligible expenses

230 ldquoMedical Emergency or Accidental Injuryrdquo means an emergent situation such as the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity including severe pain such that a prudent layperson who possesses average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individualrsquos health or to a pregnancy in the case of a pregnant woman serious impairment of bodily functions or serious dysfunction of any bodily organ or part Active labor is included if a time at which (a) delivery is imminent (b) there is inadequate time to effect safe transfer to another hospital prior to delivery or (c) a transfer may pose a threat to the health and safety of the patient or the unborn child and such other acute conditions

231 ldquoMedically Necessaryrdquo means health care services provided by the Plan which adhere to nationally recognized and scientific evidence-based standards appropriate in terms of type amount frequency level setting and duration for the Memberrsquos diagnosis or condition

232 ldquoMemberrdquo means a Subscriber or Dependent eligible to receive services under this Certificate and the Group Operating Agreement and who has enrolled in the Plan

233 ldquoNon-Participating Providerrdquo means those physicians health professionals hospitals and other facilities that have not contracted with the Plan Non-Participating Providers are not listed in the Provider Directory Services from a Non-Participating Provider are not Covered unless Prior Authorized by the Plan

234 ldquoOpen Enrollment Periodrdquo means that limited period of time during which eligible persons are given the opportunity to enroll in the Plan

235 ldquoPlanrdquo means Total Health Care USA Inc

5

236 ldquoPlan Yearrdquo means a twelve (12) month period of benefit coverage that begins on January 1 Deductible amounts are reset to zero at the beginning of each Plan Year

237 ldquoPreferred Brand Name Drugrdquo means a prescription drug approved by the Food and Drug Administration (FDA) It is protected by a patent made by a single company and sold under the brand name

238 ldquoPremiumrdquo means the amount of money prepaid monthly by a Group including Subscriber contributions if any on behalf of the Members

239 ldquoPreventive Benefitsrdquo means Covered Services that are meant to prevent disease while it is more easily treatable These are defined by the US Preventive Services Task Force A and B recommendations

240 ldquoReferral Facilityrdquo means any legally qualified and state-licensed intermediate care facility skilled nursing facility Hospice or Hospital that provides services to Members under the orders of a Treating Physician Affiliated Physician or Referral Physician when admission is authorized by the Planrsquos Medical Director or hisher designee

241 ldquoReferral Physicianrdquo means a physician other than a Treating Physician who is licensed to practice medicine and who delivers medical care to a Member on the referring order of a Treating Physician

242 ldquoRemitting Agentrdquo means the Group or the person designated by the Group who is responsible for the payment of the monthly Premiums

243 ldquoSemi-private Roomrdquo means Hospital accommodations where there are two (2) or more beds to a room

244 ldquoService Areardquo means the geographic area where the Plan is available and readily accessible to Members and where the Plan has been approved by the State of Michigan to market its services

245 ldquoSpecialty Drugsrdquo means drugs listed on the Approved Drug List meeting certain criteria such as (1) Drugs or drug classes whose cost on a per- month or per- dose basis exceeds the

threshold established by the Centers for Medicare and Medicaid Services or(2) Drugs that require special handling or administration or(3) Drugs that have limited distribution or(4) Drugs in selected therapeutic categories

Specialty Drugs are limited to a maximum of a 31-day supply per prescription or refill

246 ldquoSpecialty Pharmacyrdquo means a Pharmacy that specializes in the handling distribution and patient management of Specialty Drugs

247 ldquoSpouserdquo means the legally married husband or wife of a Subscriber

6

248 ldquoSubscriberrdquo means an individual who enters into an HMO contract or on whose behalf an HMO contract is entered into with an HMO that has received a certificate of authority from the State of Michigan and to whom an HMO contract is issued(1) Who meets all eligibility criteria established by the Group Operating Agreement and this

Certificate and(2) Who has completed an Enrollment Application which has been received by the Plan and(3) Who resides within the Service Area at the time of application and(4) For whom Premiums have been received

249 ldquoTreating Physicianrdquo means an individual licensed to practice medicine or osteopathy and is responsible for a Memberrsquos care with regards to a particular diagnosis or treatment

250 ldquoUrgent Conditionrdquo means a medical condition manifesting in an urgent but not life-threatening condition such that the absence of medical attention within a 24 hour period from the onset of symptoms could reasonably be expected to result in further complication of the patientrsquos conditions or deterioration of the patientrsquos condition Such conditions may include(1) High fever(2) Uncontrolled vomiting andor diarrhea(3) Ear ache(4) Minor wounds

251 ldquoUSPTFrdquo means the United States Preventative Task Force available online at httpwwwuspreventiveservicestaskforceorg which is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists pediatricians family physicians gynecologistsobstetricians nurses and health behavior specialists) The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening counseling and preventive medications) and develops recommendations for primary care clinicians and health systems Preventive Services in the Certificate are based on these recommendations as noted in 239

252 ldquoNon-Elective Abortionrdquo means any of the following (1) The intentional use of an instrument drug or other substance or device by a physician to terminate a womanrsquos pregnancy if the womanrsquos physical condition in the physicianrsquos reasonable medical judgment necessitates the termination of the womanrsquos pregnancy to avert her death (2) Treatment upon a pregnant woman who is experiencing a miscarriage or has been diagnosed with an ectopic pregnancy

ARTICLE III ENROLLMENT EFFECTIVE DATE OF COVERAGE PREMIUMS

301 Enrollment(1) Persons meeting the Grouprsquos and Planrsquos eligibility requirements during an Open Enrollment

Period may enroll in the Plan only during that Open Enrollment Period In order to enroll an Enrollment Application must be completed and received by the Group during the Open Enrollment Period

7

A person who is an eligible person at the time of an Open Enrollment Period and not already a Subscriber who fails to enroll during such Open Enrollment Period shall not be entitled to enroll at a later date except during a subsequent Open Enrollment Period

(2) Persons who join the Group between Open Enrollment Periods or otherwise become eligible to enroll in the Plan for the first time may do so by completing an Enrollment Application within thirty (30) days of attaining eligibility pursuant to the Group Operating Agreement In the event that such a newly eligible person fails to complete and submit an Enrollment Application within this 30-day time period the person shall be entitled to enroll in the Plan only during a subsequent Open Enrollment Period

(3) All newborn coverage starts at birth To be covered a Member must enroll the newborn and pay any premium within thirty-one (31) days of birth

302 Effective Date of Coverage(1) Except as limited in subsection (3) below the effective date of coverage for Members

who enroll during an Open Enrollment Period will be the date agreed upon in the Group Operating Agreement provided that the signed Enrollment Application and appropriate Premium have been received by the Plan

(2) Except as limited in subsection (3) below and unless otherwise provided in the Group Operating Agreement the effective date of coverage for newly eligible Members who enroll between Open Enrollment Periods shall be the first day of the month following the month of the Planrsquos receipt of the signed Enrollment Application and Premium

(3) The effective dates of coverage set out above will be deferred for persons not already Members of the Plan who are confined to any prison on the effective date until the day after the person is released from the prison facility

303 PremiumsPremiums shall be paid to the Plan at the rate established by the Plan for coverage under this Certificate as set forth in a written notice by the Plan to the Remitting Agent All Premiums are to be remitted on a monthly basis on or before the first day of each month unless otherwise agreed upon in writing by the Plan and Remitting Agent If the Group pays the Premium to the Plan during the thirty (30) day Grace period there will be no lapse in coverage

If the Premium is not received within the Grace Period the Plan may terminate the Group Operating Agreement and this Certificate in accordance with Article X In the event of termination the Plan reserves the right to recover from the Group the cost of services rendered during the period following the due date and to reject claims submitted by providers for services rendered during the period following the due date Termination shall be effective retroactively to the due date of said Premium

304 Renewability Coverage at the end of the Contract Year is guaranteed to be renewed except for the following reasons(a) Non-payment f Premium(b) Fraud(c) Member moves outside of the Plan Service Area(d) The Plan withdraws from the market

8

305 Health Factors The Plan attests that it does not limit benefits based on genetic testing when Medically Necessary It does not use information obtained from genetic testing to limit coverage adjust premiums based upon such information It does not request or require such testing or collect such information from an individual at any time for underwriting purposes The Plan also attests it does not limit benefits based upon health status medical condition claims experience receipt of health care medical history evidence of insurability or disability

ARTICLE IV GENERAL CONDITIONS

401 This policy including the applicable riders and endorsements the application for coverage if specified by the insurer the identification card if specified by the insurer and the attached papers if any constitutes the entire contract of insurance No change in this policy is valid until approved by an executive officer of the insurer and unless the approval is endorsed on this policy or attached to this policy An insurance producer does not have authority to change this policy or to waive any of its provisions

402 Primary Care Provider In completing the Enrollment Application each Subscriber must select any available Affiliated PhysicianPCP That physician may be a general practitioner family practitioner internist pediatrician nurse practitioner or physician assistant Each Member agrees that all Authorized Benefits and Services must be provided by or authorized through this selected Affiliated PhysicianPCP except in the event of a Medical Emergency or Accidental Injury When necessary your Affiliated PhysicianPCP will work with other Affiliated Providers and Specialty Physicians to ensure you receive the care you need For help with the selected Affiliated PhysicianPCP or for more information the Member should call the Planrsquos Customer Service Department at (800) 826-2862 You may change your PCP at any time

403 Members do not need approval from the Affiliated PhysicianPCP to see most participating Specialty Physicians or Affiliated Providers (see 502 XIX) All Covered Services must be received by participating providers unless Prior Approved by the Plan If you do not receive an approval from the Plan prior to seeking Covered Services from a Non-Participating Provider you will be responsible for payment A referral from your Affiliated PhysicianPCP is not enough for the services to be covered If the Plan gives prior approval for the referral to a Non-Participating Provider your PCP or the ordering provider will be notified

404 Nothing contained within this Certificate shall interfere with the professional relationship between the Member and the physician providing care Each Member shall have the right to choose to the extent feasible and appropriate the physician and other health care professionals responsible for hisher primary care

405 No officer agent or representative of the Plan except the Executive Director is authorized to vary the terms or conditions of this Certificate in any way or to make any promises or agreements supplemental to this Certificate Any supplemental agreements or variances to the terms or conditions of this Certificate must be in writing signed by the Executive Director of the Plan

9

406 The Authorized Benefits and Services provided under this Certificate are solely for the individual benefit of the Members and cannot be transferred or assigned If any Member aids attempts to aid or knowingly permits any other person not a Member of the Plan to obtain benefits or services from or through the Plan that Memberrsquos coverage under this Certificate shall be terminated automatically and the Member shall be responsible for payment for any services rendered to such other person The theft or wrongful use delivery or circulation of a Member identification card may constitute a felony under Michigan law

407 This Certificate supersedes all previous contracts or certificates between the Plan the Group and the Members

408 Any notice required to be given by the Plan the Group or a Member shall be deemed to have been duly given if in writing and personally delivered or deposited in the United States mail with postage prepaid addressed as applicable to the Remitting Agent to the Member at the last address on record at the Planrsquos principal office or to the Plan at 3011 W Grand Blvd Suite 1600 Detroit MI 48202

409 The Plan shall not be liable for any delay or failure of an Treating Physician Affiliated Provider Referral Physician or Referral Facility to provide services due to lack of available facilities or personnel if the lack is a result of circumstances beyond the Planrsquos control In the event of circumstances beyond the Planrsquos control the Plan shall attempt to arrange Authorized Benefits and Services insofar as practical according to its best judgment and within the limitations of facilities and personnel then available Circumstances beyond the Planrsquos control include but are not limited to complete or partial disruption of facilities war riot civil insurrection epidemic labor disputes unavailability of supplies disability of a significant part of an Affiliated Providerrsquos personnel or similar causes

410 Complaint Grievance and Appeal Process

GrievancesAppeals The Plan will provide each Member with a written explanation of the procedure upon enrollment in the Plan andor at any time upon request A Member can call the Plan or write to the Plan to file a written grievance at

Total Health Care USA Attention Grievance Coordinator 3011 W Grand Blvd Suite 1600 Detroit Ml 48202 Phone (313) 871-7889 Fax (313) 871-0196 e-mail resultsthc-onlinecom

A grievance (also known as appeal) may be filed due to a denial of payment an adverse determination or other dissatisfaction with the Plan An adverse determination means health care services have been reviewed and denied reduced or terminated An untimely response to a request becomes an adverse determination The Member or authorized representative

10

has one hundred and eighty (180) days from the date of the adverse determination letter to file a grievanceappeal An authorized representative must have written permission to represent the Member This consent must be included with the grievanceappeal

The member grievance process includes two steps The first step is to file the grievance and the second step is to appeal the resolution A Member can file the grievance telephonically or in writing Once the grievance has been filed the Member can request the Plan to arrange a meeting with the Appeal Review Committee The Member can discuss the grievanceappeal with the committee The Member or authorized representative may attend a meeting in person or by telephone A person not involved in the first decision will review the grievanceappeal No one who reports to the person involved in the initial decision can review the grievance appeal The person who reviews the grievanceappeal will be of similar specialty

A Member has the right to have benefits continue pending resolution of the grievance appeal The Member may also authorize a representative to act on their behalf in the grievanceappeal process The Member has the right to send additional documentation with the grievanceappeal

A medical pre-service grievanceappeal takes at most 15 days and a pre-service appeal also takes at most 15 days The whole process will be completed within 30 days Similarly a post-service grievance takes at most 30 days and a post-service appeal also takes at most 30 days The whole process will be completed within 60 days The time frame may be extended up to ten (10) business days if the Member requests an extension or if the Plan can show that there is need for additional information and can demonstrate that the delay is in the Memberrsquos best interest If the Plan utilizes the extension the Member will receive written notice of the reason for the delay The Member will be notified in writing of the final decision If the decision upholds the denial an external appeal can be filed The final letter informs the Member of the external appeal rights and how to file the appeal

Expedited GrievanceAn expedited review of a grievance will be made when a physician notifies us verbally or in writing that waiting the thirty (30) days would cause the Member to have severe pain or put their life at risk The physician must be able to support the attestation The grievance must be received within ten (10) days of the denial

After filing an expedited internal grievance with Total Health Care an appeal and request may be filed for an expedited external review with the Department of Insurance and Financial Services(DIFS) If a request for an expedited grievance is denied it is changed to a thirty (30) day grievance

A decision about an expedited grievance is made no later than seventy-two (72) hours after it is received A request for an extension of the decision time moves the grievance to a thirty (30) day grievance

Total Health Care will notify the Member of the decision by phone The decision will also be mailed to the Member within two (2) business days

11

If the decision upholds the denial the specific reasons for the final denial will be provided The notification letter will include the benefit provision guideline protocol or other criteria used Upon request access to and copies of all papers related to the grievance are provided

External Appeal RightsA Member or authorized representative has the right to request an external review from DIFS The request should be made after receiving Total Health Carersquos final decision Notification of the final decision completes the Total Health Care internal appeal process

A Member or authorized representative must file the DIFS Health Care-Request for External Review Form to be given an external review A copy of the Health Care-Request for External Review Form will be included with the final decision letter Members may also call DIFS at 1-877-999-6442 to have a form mailed The form should be filed no later than one hundred twenty (120) days after receipt of the final decision letter

When appropriate DIFS will request a recommendation by an independent review organization The independent review organization is not a part of Total Health Care The Director of DIFS will issue a final order To ask questions about the external review process contact the Total Health Care Grievance Coordinator at (313) 871-7889 or 1-800-826-2862 x889 To request an independent review write to

Department of Insurance and Financial ServicesHealthcare Appeals Section Office of General CounselPO Box 30220Lansing MI 48909-7720Or call (877) 999-6442Or fax (517) 241-4168

411 All Member protected health information (ldquoPHIrdquo) is maintained in a manner that assures confidentiality consistent with applicable law PHI includes such information as a Memberrsquos name address phone number Social Security Number demographic information and any information related to hisher health condition or diagnosis The Member has the right to inspect and review their medical records The Plan will not use or disclose PHI concerning Members andor their medical treatment other than for purposes of treatment payment or health care operations except upon written authorization of the Member or as otherwise required by law Any such disclosure of PHI will be limited to that which is minimally necessary

412 The Plan may adopt reasonable policies procedures and rules to promote orderly and efficient administration of this Certificate Direct questions about such policies in writing to

Total Health Care USA3011 W Grand Boulevard Suite 1600Detroit MI 48202Attn Marketing Dept

12

413 The Member identification (ID) card is the property of the Plan Each Member understands and agrees to return the Member identification card upon request of the Plan

414 Legal Actions No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this policy No such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be furnished

415 Written Documents As a Member of the Plan the Plan will provide you upon your request with a description of any of the following To request this information please contact the Member Services Department at (313) 871-2000 or mail your request to the Member Services Department Be sure to include your Member ID number on your request Request should be mailed to

Total Health Care USA3011 W Grand Blvd Suite 1600Detroit MI 48202Attn Marketing Dept

1 Information Concerning Affiliated Providers The Member Provider Directory includes the names of Plan Affiliated Providers specialty or type of practice practice location and information concerning accessibilityavailability Requests may be made for the following additional information(a) Clarification with respect to the information contained in the Provider Directory(b) Professional credentials of Affiliated Providers including but not limited to

professional degrees dates of certification by professional boards and other professional bodies and affiliation status of Affiliated PhysicianPCPs Providers Affiliated Facilities and Affiliated Hospitals

2 Financial Relationships with Affiliated Providers Information concerning the nature of financial relationships between the Plan and its Affiliated Providers can include(a) Whether a fee-for-service arrangement exists under which the Affiliated Provider is

paid a specific amount for each Covered Service rendered to a Member(b) Whether a capitation arrangement exists under which a fixed amount is paid to

the Affiliated Provider for all or a specified set of Authorized Benefits and Services that are or may be rendered to the Member

(c) Whether payments to Affiliated Providers are based on standards relating to cost quality andor patient satisfaction

3 Licensure Verification information concerning disciplinary action and open formal complaints filed against a health professional or Affiliated Provider is available through the Department of Licensing and Regulatory Affairs at httpwwwmichigangovlara You may also request a copy by emailing LARAFOIAInfomichigangov or fax to 517-335-4037

4 Benefits This Certificate of Coverage together with any Riders and the Member Handbook provided to Members contains a description of the benefits available to

13

Plan Members including rules regarding accessing benefits such as prior authorization requirements Memberrsquos financial participation including Co-Payments Deductibles and Coinsurance drug formulary requirements if any and exclusions and limitations applicable to the specific categories of benefits provided If you require clarification with respect to any of this information please contact the Member Services Department

5 Affiliated Provider Termination In the event of termination Members in an ongoing course of treatment with an Affiliated PhysicianPCP or Referral Physician shall be permitted to continue such treatment with Plan authorization as follows(a) For a period of ninety (90) days from the date the Member is notified of the

termination(b) If the Member is in the second or third trimester of pregnancy treatment shall

continue through post-partum care(c) If it is determined that the Member is terminally ill as defined in Section 5653 of the

public health code treatment will continue for the remainder of the Memberrsquos life for care directly related to the treatment of terminal illness

416 A deductible carry-over from the prior health insurance carrier applies for eligible expenses incurred within ninety (90) days of the Grouprsquos effective date with Total Health Care USA The Member must provide documentation of the expense within sixty (60) days of the initial Total Health Care USA effective date The deductible carry-over does not accumulate toward the Out-of-Pocket Maximum

417 Autopsy The Plan at its own expense shall have the right and opportunity to examine a Member when and as often as it may reasonably require during the pendency of a claim to make an autopsy in case of death where it is not forbidden by law

418 Claims Provisions(a) When a Member receives Authorized Benefits and Services from an Affiliated Provider

Member will not be required to pay any amounts except for Co-Pays Deductibles and Coinsurance Member will not be required to submit any claim forms for Authorized Benefits and Services received from Affiliated Providers Member is responsible for the cost of any services received from non-Affiliated Providers or Physicians unless those services were arranged for and approved in advance by your Affiliated Physician PCP and the Plan or they were the result of a Medical Emergency Members will receive an Explanation of Benefits from the Plan and the Provider of Services will receive an Explanation of Payment upon filing a Clean Claim

(b) Member Self Pay If a Member is required to pay for an Authorized Benefit and Services (other than for applicable Deductible Coinsurance or Co-Pay) a written request for reimbursement can be made to the Plan The request must include a bill that shows exactly what services were received including the diagnosis and CPT codes the date place of service and rendering provider A statement that shows only the amount owed is not sufficient Reimbursement will be made less any applicable Co-pay

14

Coinsurance and Deductible If you have questions about what is required call Total Health Care USA Customer Service Department at (800) 826-2862

(c) Reimbursement Request Time Limit Request for reimbursement for a self-pay Authorized Benefit and Service must be made within sixty (60) days of the date in which the services were obtained Requests for reimbursement beyond the sixty (60) days can be limited or refused by the Plan unless it is not reasonably possible to provide proof of payment in the required time

The required information must be made available as soon as reasonably possible Upon review of the request for reimbursement the Plan may require additional information to process a reimbursement request Unless Member is legally unable and therefore unable to respond the Plan will not be liable for a claim or reimbursement request if additional information is not received within sixty (60) days of the request The Planrsquos right to that information may be limited by state or federal law Emergency service unless the Member is legally incapacitated Send itemized medical bills promptly to

Total Health Care USA IncClaims Department3011 W Grand Boulevard Suite 1600Detroit MI 48202

(d) Overpayment If the Plan pays an amount under this Certificate and it is later shown that a lesser amount should have been paid the Plan is entitled to a refund of the excess This applies to payments made to the Member or to the Provider of services supplies or treatment

ARTICLE V COVERED BENEFITS AND SERVICES

The following services are covered with no Deductible Coinsurance or Co-pay(1) Preventive Health Services (See Section 501)(2) Prenatal and Postnatal Care including maternity classes without a referral or authorization(3) Weight Loss Services

Members can receive these services without cost-share at any time during the Calendar Year All other services are subject to Deductible before the Plan is responsible to pay Once the Deductible is satisfied all items other than noted above are subject to Coinsurance or Co-pay based on Rider until the Maximum Out-of-Pocket is reached for the Calendar Year Co-pays do not accrue towards Maximum Out-of-Pocket Expense

501 Preventive Health Care Services - available without Co-Pays Coinsurance or Deductibles(a) Immunizations (doses recommended ages and recommended populations vary based on

recommendations from the Advisory Committee on Immunization Practices [CDC])bull Certain vaccines ndash children from birth to age 18 bull Certain vaccines ndash all adults

(b) Certain Drugsbull Aspirin ndash men and women of certain ages

15

bull Folic Acid supplements ndash women who may become pregnantbull Fluoride Chemoprevention supplements ndash children without fluoride in their water sourcebull Gonorrhea preventive medication ndash all newborns

(c) Screening and Counseling Services for Adultsbull Abdominal Aortic Aneurysm ndash men of specified ages who have ever smoked

(one-time only) bull Alcohol Misuse ndash all adults bull Blood Pressure ndash all adults bull Cholesterol ndash adults of certain ages or adults at higher risk bull Colorectal Cancer ndash adults over 50 bull Depression ndash all adults bull Type 2 Diabetes ndash adults with high blood pressure bull Diet and physical activity counseling ndash adults at higher risk for chronic diseasebull Hepatitis B amp C for high risk adults bull HIV ndash all adults at higher risk and pregnant women bull Obesity ndash all adults bull Sexually Transmitted Infection (STI) ndash prevention counseling for adults at higher riskbull Tobacco Use ndash all adults (includes cessation interventions for tobacco users) bull Syphilis ndash all adults at higher riskbull Tuberculosis

(d) Screening and Counseling Services for Women (Including Pregnant Women)bull Bacteriuria (urinary tract or other infection screening) ndash pregnant women bull BRCA (counseling about genetic testing) ndash women at higher risk bull Breast Cancer Mammography ndash every 1 to 2 years for women over 40 bull Breast Cancer Chemoprevention ndash women at higher risk bull Breast Feeding ndash interventions to support and promote breast feeding bull Cervical Cancer ndash sexually active women bull Chlamydia Infection ndash younger women and other women at higher risk bull Gonorrhea ndash all women at higher risk bull Hepatitis B ndash pregnant women at their first prenatal visit bull Osteoporosis ndash women over age 60 depending on risk factors bull Rh Incompatibility ndash all pregnant women and follow-up testing for women at higher risk bull Tobacco Use ndash all women and expanded counseling for pregnant tobacco users bull Syphilis ndash all pregnant women or other women at increased risk

(e) Assessments and Screenings for Children Alcohol and Drug Use Assessments ndash adolescentsbull Autism Screening ndash children at 18 and 24 monthsbull Behavioral Assessments ndash children of all agesbull Cervical Dysplasia Screening ndash sexually active females bull Congenital Hypothyroidism Screening ndash Newbornsbull Developmental Screening ndash adolescents aged 12 to 18 years bull Hearing Screening ndash all newborns bull Hemoglobinopathies or Sickle Cell Screening ndash all newborns

16

bull Hepatitis B - high risk adolescentsbull HIV Screening ndash adolescents at higher riskbull Obesity Screening and Counseling ndash children of all agesbull Phenylketonuria (PDU) Genetic Disorder Screening ndash all newbornsbull Sexually Transmitted Infection (STI) Prevention Counseling ndash adolescents at higher riskbull Skin cancer behavioral counselingbull Tobacco use interventionsbull Vision Screening ndash all children

(f) In compliance with the consumer protections of the Patient Protection and Affordable Care Act this ldquonon-grandfathered health planrdquo includes preventive health care services that address health needs specific to womenbull Well-women visitsbull Screening for gestational diabetesbull Human papilloma virus testingbull Counseling for sexually transmitted infectionsbull Counseling and screening for human immune-deficiency virusbull Womenrsquos prescribed contraceptive methods (including womenrsquos sterilization

procedures) and counselingbull Breastfeeding support prescribed supplies and counselingbull Screening and counseling for interpersonal and domestic violence

Additional information and limitations regarding womenrsquos contraceptive methods and counseling

bull Womenrsquos contraceptive methods (including womenrsquos sterilization procedures) and counseling are not Covered under this Certificate or under any prescription drug Rider to the Certificate for Members of a plan established or maintained by a Religious employer certified as exempt from providing such Coverage under the Patient Protection and Affordable Care Act

bull Brand name oral and injectable contraceptive drugs are only Covered under preventive health care services if approved by the Plan as Medically Necessary If your plan includes a prescription drug Rider and services are provided by a Participation Pharmacy brand name oral and injectable contraceptive drugs are Covered at the Preferred Brand Name Copayment or Non- Preferred Brand Name Copayment described in your prescription drug Rider unless otherwise approved by the Plan If you elect to receive a Brand Name Drug when an equivalent Generic Drug is reasonably available you may also be responsible for the difference in cost between the Brand Name Drug and the Generic Drug

bull The benefits in this Section are subject to change based on provisions of the Affordable Care Act Visit the CMS web site at wwwhealthcaregovprevention for the most up-to-date services

502 Inpatient Hospital CareWhen a Member is admitted to an Affiliated Hospital or any other Hospital upon authorization of a Treating Physician and the Planrsquos Medical Director or hisher designee or

17

through an emergency admission the Member is entitled to the following Authorized Benefits and Services when deemed necessary for the medical surgical obstetrical and related diagnosis and treatment of the Member(a) A semi-private room including general nursing services meals and special diets(b) Use of intensive care units operating rooms delivery rooms recovery rooms and other

special treatment rooms(c) Anesthesia services(d) Laboratory examinations including typing of blood donors and other diagnostic and

pathological services(e) All necessary medical and surgical supplies(f) Use of X-ray and other diagnostic and therapeutic services(g) Drugs biologicals and related preparations as prescribed by the attending physician(h) Maternity and nursery care of at least forty-eight (48) hours following vaginal delivery

ninety-six (96) hour minimum stay in the case of a cesarean section delivery(i) Radiation and inhalation therapy(j) Medical rehabilitative services and physical therapy which can be expected to result in

significant improvement of the Memberrsquos condition(k) Other inpatient services medically necessary for admission diagnosis and treatment of

the Member

503 Organ and Tissue TransplantsOrgan or body tissue transplant is covered when(1) Evaluations for transplants and transplants of the following organs at a facility approved

by the Plan but only when we have approved the transplant as Medically Necessary and non-experimental(a) Bone marrow or stem cell(b) Cornea(c) Heart(d) Kidney(e) Liver(f) Lung(g) Pancreas(h) Small bowel(i) Related Services

(2) Member is enrolled in Total Health Care USArsquos Case Management Program during the evaluation pre and post-transplant care and

(3) The approved transplant is performed in a Total Health Care USA authorized facility(4) Expenses related to Computer organ bank searches and any subsequent testing necessary

after a potential donor is identified unless covered by another health plan(5) Typing or screening of a potential donor only if the person proposed to receive the

transplant is a Member(6) Donorrsquos medical expenses directly related to or as a result of a donation surgery if the

person receiving the transplant is a Member and the donorrsquos expenses are not covered by another health benefit plan

18

(7) One comprehensive evaluation per transplant except as permitted by our medical policies(8) Transplants also include the necessary hospital surgical lab and X-ray services for a non-

member donor unless the Member donor has coverage for such service

Non-Covered Services include(a) Community wide searches for a donor(b) All donor expenses even those of Members for transplant recipients who are not

Members(c) Transplants of organs when the transplant is considered experimental or investigational

504 Outpatient Services(1) Outpatient surgical care including routine surgical procedures that do not require the use

of inpatient hospital facilities and can be performed on an outpatient basis at a Hospital ambulatory surgical center or physician office Such services include surgical scopic procedures including but not limited to arthroscopy hysteroscopy laparoscopy

(2) Therapeutic and diagnostic laboratory pathology radiology and special diagnostic services which are medically necessary for the diagnosis or treatment of a disease injury or medical condition

(3) Medical and surgical supplies(4) Pre-hospital admission screening procedures which have been authorized by a Treating

Physician andor the admitting physician

505 Professional ServicesServices listed in Article V (other than those designated as Non-Covered) are covered when provided by an Affiliated Provider during an office home or Hospital visit for the diagnosis and treatment of an Authorized Benefit and Service when approved in advance by the Plan if required including services necessary to treat a Medical Emergency or Urgent Care situation Affiliated PhysicianPCPs are not required to provide referrals to Affiliated Specialty Physicians for office-based services including ObGyn care with the exception of Chiropractic and Podiatry Care Professional Services include(1) Office visits at the Memberrsquos Primary Care Physician including annual physical

examinations(2) Specialty physician care(3) Drugs administered at the primary care office including Allergy shots(4) The following Drugs are excluded from the Prescription Drug Benefit and are covered

under the Medical Benefit portion of Memberrsquos Certificate of Coverage These include(a) Injectable and infusible drugs administered in an inpatient or emergency setting(b) Injectable and infusible drugs requiring administration by a Health Professional in a

medical office home or outpatient facility(5) Therapeutic and diagnostic laboratory pathology radiology and special diagnostic

services which are medically necessary for the diagnosis or treatment of a disease injury or medical condition

(6) Prenatal and Postnatal care(7) Nutritional counseling and health education services

19

(8) Pre-hospital admission screening procedures which have been authorized by a Treating Physician andor the admitting physician

(9) Vision and hearing screening examinations for Dependents through the completion of the calendar year in which they attain the age of eighteen (18) years to determine the need for vision andor hearing corrections

(10) Infertility counseling testing and treatment for the underlying cause of infertility

506 Rehabilitative and Habilitative Medicine Services(1) Short-term medical Rehabilitative Services for conditions which Treating Physician

expects will result in significant improvement of a Memberrsquos condition within a period of two (2) months including(a) Physical Occupational Chiropractic and Osteopathic Manipulations for a combined

30 visits per calendar year(b) Speech therapy for a maximum of 30 visits per calendar year(c) Cardiac and pulmonary rehabilitation for a combined 30 visits per calendar year

(2) Habilitative Services including but not limited to all therapies for developmental delays and cognitive disorders including(a) Physical Occupational Chiropractic and Osteopathic Manipulations for a combined

30 visits per calendar year(b) Speech therapy for a maximum of 30 visits per calendar year(c) Sensory integration therapy(d) Cognitive rehabilitative therapy (neurological training or retraining)(e) Summer programs meant to maintain physical condition or developmental status

during periods when school programs are unavailable(f) Therapy for purposes of maintaining physical condition or maintenance therapy for

a chronic condition including but not limited to cerebral palsy and developmental delays

(3) Habilitative and Rehabilitative Devices

Short-term Rehabilitative Medicine Services are covered if(1) Treatment is provided for an illness injury or congenital defect for which you have

received corrective surgery and(2) Services are provided in an outpatient setting or in the home and(3) You cannot receive these services from any federal or State agency or any local political

subdivision including school districts and(4) Services result in meaningful improvement within 90 days in your ability to do important

day-to-day activities that are necessary in your life roles

Non-Covered Professional Rehabilitative and Habilitative Services include(1) Therapy is not covered if there has been no meaningful improvement in the ability to do

important day-to-day activities that are necessary in your life roles within ninety (90) days of starting treatment

(2) Craniosacral therapy(3) Prolotherapy

20

(4) Rehabilitation services obtained from non-Health Professionals including massage therapists

(5) Relational educational and sleep therapy and any related diagnostic testing This exclusion does not apply to therapy or testing provided as part of Affiliated Hospital or Affiliated Facility services outside the scope of practice of the servicing provider

(6) Services outside the scope of practice of the servicing Provider(7) Strength training and exercise programs(8) Visual training and sensory integration therapy(9) Vocational rehabilitation including work training work related therapy work hardening

work site evaluation and all return to work programs employment counseling or those that are in connection with examinations for insurance or employment screening except as they may be incidental to an annual health exam

(10) Extra-spinal manipulation and related services performed by a chiropractor are not covered

507 Plastic Surgery Medically Necessary(1) All services defined as Medically Necessary Plastic Surgery require Prior Authorization

Approval by the Planrsquos Medical Director

Covered Services(a) Blepharoplasty of upper lids(b) Breast Reduction(c) Panniculectomy(d) Surgical Treatment of Male Gynecomastia(e) Surgery to correct Sleep Apnea(f) Rhinoplasty(g) Septorhinoplasty

Non-Covered Services(1) Any procedures deemed for cosmetic purposes primarily to improve the way the body

looks Coverage is excluded for but not limited to(a) Blepharoplasty of lower lids(b) Breast augmentation except when provided as part of post-mastectomy reconstructive

services(c) Chemical peel for acne(d) Collagen implants(e) Diastasis recti repair(f) Excision or repair of excess or sagging skin however a panniculectomy is covered

according to Plan medical policies(g) Fat grafts unless an integral part of another Authorized Benefit and Service(h) Hair transplants or repair of any congenital or acquired hair loss including hair

analysis(i) Liposuction unless an integral part of another Authorized Benefit and Service(j) Orthodontic treatment even when provided along with reconstructive surgery

21

(k) Removal for excessive hair growth by any method even if caused by an underlying medical condition

(l) Rhytidectomy (wrinkle removal)(m) Rhinophyma treatment(n) Salabrasion(o) Spider vein removal(p) Tattoo removal

(2) Reconstructive Surgery to correct congenital birth defects andor effects of Illness or Injury if(a) The defects andor effects of Illness or Injury cause clinical functional impairment

ldquoClinical functional impairmentrdquo exists when the defects andor effects of Illness or Injuryi causes significant disability or major psychological trauma (psychological reasons

do not represent a medical or surgical necessity unless you are undergoing psychotherapy for issues solely related to the Illness or Injury for which the reconstructive surgery is requested)

ii interfere with employment or regular attendance at schooliii require surgery that is a component of a program of reconstructive surgery for a

congenital deformity or trauma oriv contribute to a major health problem and

(b) there is reasonable expectation that the surgery will correct the condition and(c) the services are approved in advance by the Plan and you receive them within two

years of the event that caused the impairment unless either of the following appliesi The impairment caused by Illness or Injury was not recognized at the time of the

event In that case treatment must begin within two years of the time that the problem is identified or

ii Your treatment needs to be delayed because of developmental reasons(d) The Plan will cover treatment to correct the functional impairment even if the treatment

needs to be performed in stages as long as that treatment begins within two years of the event causing the impairment and as long as you remain a Member

Gender TransitionGender Dysphoria Covered Servicesbull Medically Necessary hospitalizations prescription drugs medical surgical and

behavioral health services as stated in other areas of this policy and subject to prior approval as noted elsewhere in this Certificate related to gender transition or gender dysphoria

508 Home Health CareWhen prescribed by a Treating Physician home health care visits are covered when the member is confined to the home under the care of a Physician receiving services under a plan of care established and periodically reviewed by a Physician and in need of intermittent skilled nursing care or physical speech occupational therapy or infusion therapy

22

509 Breast Cancer Screening Diagnostic Treatment and Rehabilitative Services(1) Breast cancer screening mammography services are covered by the Plan Coverage is

for one (1) mammography screening every year for women forty (40) years and older and one (1) mammography during a five (5) year period for women between the ages of thirty-five (35) and forty (40) years Any other medically indicated mammography is covered

(2) Breast cancer diagnostic services include procedures intended to aid in the diagnosis of breast cancer including but not limited to surgical breast biopsy pathologic examination and interpretation

(3) Breast cancer treatment delivered on an inpatient or outpatient basis including but not limited to surgery radiation therapy chemotherapy hormonal therapy and related medical follow-up services

(4) Other Breast Services and Treatment Following a Mastectomy(a) Reconstruction of the breast on which the mastectomy has been performed(b) Surgery and reconstruction on the breast to produce a symmetrical appearance(c) Prosthesis (breast implant) and(d) Treatment for physical complications of the mastectomy including lymphedema(e) Any other procedure intended to improve the results or ameliorate the debilitating

consequences of treatment of breast cancer including psychological and social support services

510 Diabetic ServicesThe Plan shall provide coverage for the following equipment supplies and educational training for the treatment of diabetes if determined to be medically necessary meets established criteria and is prescribed by a licensed allopathic or osteopathic physician(1) Blood glucose monitors(2) Blood glucose monitors for the legally blind(3) Test strips for glucose monitors visual reading and urine testing strips lancets and spring-

powered lancet devices(4) Syringes(5) Insulin pumps and medical supplies required for the use of the insulin pump(6) Diabetes self-management training to ensure that Members with diabetes are trained as to

the proper self-management and treatment of the diabetic condition(7) Insulin and other medications for the treatment of diabetes and associated conditions if

the Member subscribes to the prescription Rider (refer to Rider for Co-Payment details)

511 Antineoplastic Drug Coverage (Chemotherapy) and Clinical TrialsThe Plan covers drugs used in antineoplastic therapy and the reasonable cost of administering them Coverage for antineoplastic drugs is provided regardless of whether the specific neoplasm for which the drug is being used as treatment is the specific neoplasm for which the drug has received approval by the Federal Food and Drug Administration and regardless of the type of neoplasm if all of the following conditions are met(1) The drug is ordered by a physician for the treatment of a specific type of neoplasm(2) The drug is approved by the Federal Food and Drug Administration for use in

antineoplastic therapy

23

(3) The drug is used as part of an antineoplastic drug regimen(4) Current medical literature substantiates its efficacy and recognized oncology

organizations generally accept the treatment(5) The physician has obtained informed consent from the patient for the treatment regimen

that includes Federal Food and Drug Administration-approved drugs for off-label indications

Experimental investigational or unproven services are not covered Additionally certain drugs for which a majority of experts believe further studies or clinical trials are needed to determine toxicity safety or efficacy of the drug are not covered

Coverage Limitationsbull Routine patient costs in connection with Certain Phase II and Phase II cancer clinical trials

may be Covered if approved in advance by the Plan Medical Director

512 Behavioral Health Services Substance Abuse Services

Covered ServicesThis plan Covers evaluation consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions Both crisis intervention and solution-focused treatment are covered Covered Services must be(a) provided by licensed behavioral Health Professionals(b) provided in licensed behavioral health treatment facilities and(c) clinically-proven to work for your condition

Mental health services are available in a variety of settings and except for outpatient services require Prior Approval from our Behavioral Health Provider You may be treated as an inpatient or as an outpatient or in the emergency room depending on your particular condition Services will generally be provided in the least restrictive place that will allow for the best results for any particular condition If you donrsquot know where to go for treatment call our Customer Service Department at (313) 871-2000 or the Planrsquos behavioral health provider at (855) 344-2416 to be directed to behavioral health experts who can answer your questions

Covered Treatment Settings Includebull Acute Inpatient Hospitalization This is the most intensive level of care Prior Approval

from our Behavioral Health Provider is required for inpatient services except in a Medical Emergency Upon discharge you will be referred to a less intensive level of care

bull Partial Hospitalization This is a non-residential level of service that is similar in intensity to acute inpatient hospitalization You are generally in treatment for more than four hours but less than eight hours daily Prior Approval from our Behavioral Health Provider is required for partial hospitalization services

bull Intensive Outpatient Treatment This is outpatient treatment that is provided with more frequency and intensity than routine outpatient treatment You are generally in treatment for up to four hours per day and up to five days per week You may be treated individually as a family or in a group

24

bull Outpatient Treatment This is the least intensive and most common type of service It is provided in an office setting generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day by a licensed behavioral Health Professional

bull Residential Mental Health Rehabilitation Treatment Services are provided to individuals who require 24-hour treatment and supervision in a safe therapeutic environment Residential treatment is a 24 hour a day7 day a week facility-based level of care which provides individuals with significant and persistent Mental Health disorders therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision and structure Prior Approval from our Behavioral Health Provider is required for Residential Services

Coverage Limitationsbull Treatment for medical complications related to certain behavioral health conditions

including but not limited to neuropsychological testing when appropriate is Covered under your medical benefits

bull Eating disorders and feeding disorders of infancy or childhood are covered at all levels of care described above based on our medical policies

bull Attention deficit hyperactivity disorders are Covered for initial evaluation and follow-up psychiatric medication management Outpatient behavioral therapy is Covered for children age 12 and under

bull Personality disorders are covered only for specific psychological testing to clarify the diagnosis

bull Organic brain disorders are Covered for initial evaluation to clarify the diagnosis and for follow-up psychiatric medication management Inpatient services for Members with organic brain disorders such as closed head Injuries Alzheimerrsquos and other forms of dementia are Covered based on our medical policies

bull Autistic Disorder including Aspergerrsquos Disorder and Pervasive Developmental Disorder not otherwise specified are Covered for initial evaluation and follow-up psychiatric medication management

bull Intellectual Disabilities are Covered for initial evaluation and follow up psychiatric medication management

Non-Covered Servicesbull Care provided in a home residential or institutional facility or other facility on a temporary

or permanent basis includingndash the costs of living and being cared for in

a) transitional living centersb) non-licensed programs orc) therapeutic boarding schools

ndash the costs for care that isa) Custodialb) designed to keep you from continuing unhealthy activities orc) typically provided by community mental health services programd) provided via telephone e-mail or Internet

25

bull Counseling and other services forndash caffeine abuse or addictionndash sexualgender identity issues including sex therapyndash antisocial personalityndash insomnia and other non-medical sleep disordersndash adoption adjustment issues including treatment for reactive attachment disorderndash marital and relationship enhancement andndash religious oriented counseling provided by a religious counselor who is not an Affiliated

Providerndash experimentalinvestigational or unproven treatments and servicesndash scholasticeducational testing Intelligence and learning disability testing and

evaluations should be requested and conducted by the childrsquos school district

Substance Use ServicesCovered Servicesbull Substance use services including counseling medical testing diagnostic evaluation and

detoxification in a variety of settings You may be treated in an inpatient or outpatient setting or emergency room depending on your particular condition Services will generally be provided in the least restrictive place that will allow for the best results for any particular condition If you donrsquot know what the most appropriate treatment setting is for your condition call our Customer Service Department for assistance The Plan follows the American Society of Addiction Medicine (ASAM) Patient Placement

bull Outpatient substance use services do not require a referral from your Affiliated PhysicianPCP or the Plan Inpatient substance use disorder services (including partial hospitalization) require Prior Approval from our Behavioral Health Provider except in a Medical Emergency

Covered Treatment Settings Includebull Inpatient Detoxification These are detoxification services that are provided while you are

an inpatient in a Hospital or sub-acute unit When provided in a medical setting services are managed by the Plan

bull Medically Monitored Intensive Inpatient Treatment Following full or partial recovery from acute detoxification symptoms this type of care is provided at an inpatient facility or sub-acute unit

bull Partial Hospitalization This is an intensive non-residential level of service provided in a structured setting similar in intensity to inpatient treatment You are generally in treatment for more than four hours but generally less than eight hours daily

bull Intensive Outpatient Programs These are outpatient services provided by a variety of Health Professionals at a frequency of up to four hours daily and up to five days per week

bull Outpatient Treatment This is the least intensive level of service It is provided in an office setting generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day

bull OutpatientAmbulatory Detoxification These detoxification services may be provided on an outpatient basis within a structured program when the consequences of withdrawal are

26

non-life-threatening These services are covered under your medical benefitsbull Residential Substance Use Rehabilitation Treatment Services are provided to individuals

who require 24-hour treatment and supervision in a safe therapeutic environment Residential treatment is a 24 hour a day7 day a week facility-based level of care which provides individuals with significant and persistent substance abuse disorders therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision and structure Prior Approval from our Behavioral Health Provider is required for Residential Services

Non-Covered Servicesbull The costs of residential treatment programs without medical monitoring institutional care

non-licensed programs half-way houses or assisted living settingsbull Non-skilled care received in a home or facility on a temporary or permanent basis

Examples of such care include room and board health care aids and personal care designed to help you in activities of daily living or to keep you from continuing unhealthy activities

bull Services for caffeine abuse or addictionbull Experimentalinvestigational or unproven treatments and services

513 Autism Services

Definitionsbull ldquoApplied behavior analysis (ABA)rdquo means the design implementation and evaluation

of environmental modifications using behavioral stimuli and consequences to produce significant improvement in human behavior including the use of direct observation measurement and functional analysis of the relationship between environment and behavior ABA involves evidence-based behavioral modification techniques under supervision of a psychiatrist psychologist or licensed Health Professional specializing in autism treatments in which positive or negative reinforcement is used to encourage or reduce certain behaviors The treatment is delivered in a highly structured and intensive program with one-to-one instruction by a trained therapist typically 15-30 hours per week over the duration of one to two years

bull ldquoAutism diagnostic observation schedulerdquo means the protocol available through western psychological services for diagnosing and assessing autism spectrum disorders

bull ldquoAutism spectrum disordersrdquo means any of the following pervasive developmental disorders as defined by the diagnostic and statistical manualndash Autistic disorderndash Aspergerrsquos disorderndash Pervasive developmental disorder not otherwise specified

bull ldquoDiagnosis of autism spectrum disordersrdquo means assessments evaluations or tests including the autism diagnostic observation schedule performed by a licensed physician or a licensed psychologist to diagnose whether an individual has one of the autism spectrum disorders

bull ldquoTreatment planrdquo means a written comprehensive and individualized intervention plan that incorporates specific treatment goals and objectives and that is developed by a board

27

certified or licensed provider who has the appropriate credentials and who is operating within his or her scope of practice when the treatment of an autism spectrum disorder is first prescribed or ordered by a licensed physician or licensed psychologist

Covered Servicesbull Diagnosis of Autism Spectrum Disorder including but not limited to assessments

evaluations or tests including the autism diagnostic observation schedule performed by a licensed physician or a licensed psychologist

bull Applied Behavioral Analysis when provided by a board certified Health Professional who has the appropriate credentials

bull Evidence-based mental health outpatient therapy for the treatment of Autism Spectrum Disorder

bull Evidence-based physical therapy occupational therapy and speech therapy services for the treatment of Autism Spectrum Disorder

bull Prescription Drugs

Coverage Limitationsbull Coverage is available for children through age 18bull Coverage must be Medically Necessary as determined in accordance with Plan medical

policies and will be considered when performed by an approved Plan facility or agency along with other criteria set forth in Plan medical policies and is limited to specific treatments outlined in those medical policies

bull Covered services for Applied Behavioral Analysis treatment are limited to $50000 benefit maximum per Contract Year as allowed by the State of Michigan

bull Coverage for Autism Spectrum Disorder services are subject to the same Deductible (if any) Copayments and Coinsurance that apply to the corresponding benefit categories shown on your Schedule of Out-of-Pocket Expenses Examples of Autism Spectrum Disorder service benefit categories include Physician Office visits outpatient mental health services physical occupational speech therapies Any day or visit limitations under these benefit categories do not apply to Autism Spectrum Disorder services All other terms and limitations apply

Non-Covered Servicesbull This Certificate of Coverage does not require the Plan to provide coverage for autism

spectrum disorders to a Member under more than one Certificate of Coverage If a Member has more than one policy certificate or contract that covers autism spectrum disorders the benefits provided are subject to the limits of this Amendment when coordinating benefits

bull Autism treatment not approved in advance by the Planbull Treatments or services provided by a Non-Participating Provider unless otherwise approved

in advance by the Planbull Treatments for Autism Spectrum Disorder that are in conflict with the Planrsquos medical policies

including non-evidence based services for the treatment of Autism Spectrum Disorderbull There is no coverage for a Member who has attained the age of nineteen (19)

28

515 Dental Services(1) Dental services are not covered Accidental Dental Surgery is covered under Oral Surgery

as noted below(2) Oral Surgery

(a) Facility ancillary and anesthesia services for limited dental services may be Covered for pediatric Members wheni a child under age seven (7) needs multiple extractions or restorationsii a total of six or more teeth are extracted in various quadrantsiii there are dental treatment needs for which local anesthesia is ineffective because

of acute infection anatomic variation or allergyiv extensive oral-facial andor dental trauma has occurred causing treatment under

local anesthesia to be ineffective or compromisedv a patient has a serious medical condition that may interfere with routine dental workvi medical services are required in connection with a dental accident

(b) Removal of sound natural teeth required in preparation for other medical procedures that are Covered under this Certificate

(c) Care of fractures of facial bones(d) Biopsy and removal of tumors or cysts of the jaw other facial bones soft tissues of the

mouth lip tongue accessory sinuses and salivary glands and ducts(e) Rebuilding or repair of soft tissues of the mouth or lip needed to correct anatomical

functional impairment caused by congenital birth defect or accidental Injury This includes treatment for abnormalities such as cleft lip or cleft palate

(f) Medical and surgical services required to correct accidental Injuries including emergency care to stabilize dental structures following Injury to sound natural teeth

(g) Treatment for oral andor facial cancer(h) Treatment for conditions affecting the mouth other than the teeth(i) Facility and ancillary services relating to dental services for adults require Prior

Authorization by the Plan

Non-Covered Services(a) Routine Dental exams cleanings and restorative services except as mentioned above(b) Dental x-rays(c) Dental surgery such as root canals and tooth extractions(d) Orthodontia and orthodontic x-rays(e) Orthognathic surgery unless specifically Covered by this Certificate(f) Dental prostheses including implants and dentures and preparation of the bone to

receive implants or dentures(g) Bite splints used for dental purposes(h) Treatment of congential dental defects such as missing or abnormally developed teeth(i) Treatment services and supplies related to periodontalinflammatory gum disease(j) Dental services required due to accidents(k) Rebuilding or repair for cosmetic purposes(l) Orthodontic treatment even when provided along with oral surgery

29

(m) Dental surgery in preparation for implants or dentures including preparation of the bone or dental surgery done in connection with any of the Covered Services listed above

(3) Orthognathic Surgery is surgical treatment to restructure the bones or the other parts of the jaw to correct a congenital birth defect the effect of an Illness or Injury or to correct other functional impairments

Covered Services(a) Referral care for evaluation and orthognathic treatment only when prior authorized by

the Plan(b) Cephalometric study and x-rays(c) Orthognathic surgery and post-operative care including hospitalization if Medically

Clinically Necessary

Coverage Limits(a) See the Orthognathic Surgery category of your Schedule of Out-of-Pocket Expense for

limitations to this benefit

516 Temporomandibular Joint Syndrome Treatment(1) Temporomandibular Joint Syndrome (TMJ) is defined as muscle tension and spasms of

musculature related to the temporomandibular joint facial and cervical muscles causing pain loss of function and neurological dysfunction

(2) When deemed Medically Necessary and provided or authorized by a Treating Physician and approved by the Medical Director the following services and treatment for Temporomandibular Joint Syndrome are Authorized Benefits and Services(a) Office visits for medical evaluation and treatment(b) Specialty referral for medical evaluation and treatment(c) X-rays of the temporomandibular joint including contrast studies but not dental X-rays(d) Palliative therapy including TENS therapy and intraoral fixation(e) Myofunctional therapy(f) Surgery to the temporomandibular joint including such as condylectomy

meniscectomy arthrotomy and arthrocentesis(3) Dental and orthodontic services treatment prosthesis and appliances for or related to

treatment for temporomandibular syndrome are not covered

517 Hospice(1) Eligibility A Member is eligible for Hospice coverage when the individual is suffering from

a disease or condition with a terminal prognosis A Member shall be considered to have a disease or condition with a terminal prognosis if in the opinion of a Treating Physician the Memberrsquos death is anticipated within six (6) months after the date of admission to Hospice The fact that a Member lives beyond the 6-month or less prognosis shall not disqualify the person from continued Hospice care In order to be eligible for Hospice coverage a Member must have knowledge of the illness and the life expectancy and elect to receive Hospice services rather than active treatment for the illness

(2) Settings The majority of Hospice care is provided in the Memberrsquos home If the Member is eligible for Hospice services but does not have a family member or friend to provide

30

the care necessary to allow the Member to remain in the home a Treating Physician shall arrange for Hospice care in a Hospice Facility

(3) Hospice Care shall address the physical psychological social and spiritual needs of the terminally ill Member and shall be designed to meet the related needs of the terminally ill Memberrsquos family through the periods of illness and bereavement

518 Medical Emergency or Urgent Care(1) Urgent Care When you have an Illness or Injury that needs immediate attention such

as cuts or sprains but it is not as serious as a Medical Emergency call your Affiliated PhysicianPCP before you seek any services If it is after hours your PCP or another Affiliated Physician acting on hisher behalf must be available 24 hours a day 7 days a week to help you determine the best place to go for care If you are out of the Service Area at that time your Affiliated PhysicianPCP will determine if you can wait for those services and supplies until you could reasonably return to receive them from an Affiliated Provider If you cannot reach your Affiliated PhysicianPCPrsquos office and your Illness or Injury needs Urgent Care go to an Urgent Care Center or Hospital emergency room Present your ID card and be prepared to pay the required Co-pay Coinsurance or Deductible

Urgent Care services received from a Non-Affiliated Provider who is located in our Service Area are not covered Urgent Care services received from a Non-Affiliated Provider who is located outside of our Service Area are covered

If you receive Urgent Care services from a Non-Affiliated Provider contact your Affiliated PhysicianPCPrsquos office as soon as possible to arrange follow-up treatment Do not return to the Urgent Care Center or emergency room for follow-up care unless it is an urgent situation or Medical Emergency Any follow-up care that is provided by a Non-Participating Provider must be Prior Approved by the Plan in order to be covered

(2) If you have a Medical Emergency seek help immediately (no prior authorizationapproval is required Co-Pays may apply and do not vary based on AffiliatedNon-Affiliated Status of the Provider) Payment for emergency services will be based on reasonable and customary charges median in-network rates or Medicare rates whichever is greater All medically necessary care required to treat a Medical Emergency including care by non-Affiliated Providers is covered

If you are confined in a Hospital as an inpatient after a Medical Emergency you (or someone on your behalf) must notify your Affiliated PhysicianPCP and the Plan as soon as it is reasonably possible about your confinement Once your inpatient stay is no longer a Medical Emergency and you have received care to the point of stabilization the Plan must approve your continued inpatient stay at any Non-Affiliated Hospital in order for it to be covered Once your condition has stabilized the Plan may require you to be transferred to an Affiliated Facility to continue to be covered

bull Following a Medical Emergency your Affiliated PhysicianPCP can provide or arrange all follow-up care with Affiliated Providers Follow-up care with Non-Participating Providers will be Covered only if you receive Prior Approval from the Plan

31

(3) Emergency TransportationAmbulance Services In a Medical Emergency the Plan will cover EMT and ambulance service to the nearest medical facility that can provide Medical Emergency care The Plan will cover ambulance transfers between facilities when prior approved All other non-emergent transportation is not covered unless prior approved by the Plan

519 Against Medical AdviceNoncompliance Members who elect to leave an Affiliated or non-Affiliated Facility or Hospital against medical advice or who are noncompliant with a medically necessary course of medical treatment and subsequently require services as a result of this noncompliance forfeit coverage of those related services Services that are needed because you left a facility against medical advice or because you are noncompliant with treatment are not covered Examples of services that may not be covered include but are not limited tobull Emergency room services shortly after you left a facility against medical advicebull A Hospital stay to treat complications caused by leaving a facility against medical advicebull A Hospital stay to treat complications caused by not taking prescribed medications such as

insulin or blood pressure medication

520 Out-of-Area Coverage Out-of-Area benefits shall be limited to inpatient and outpatient care for Medical Emergencies or Accidental Injuries only Members traveling outside the Service Area are not covered for Out-of-Area obstetrical services and related Hospital care within four (4) weeks of the estimated date of delivery as determined by the Affiliated PhysicianPCP whether or not the obstetrical services and related Hospital care were required as a result of a Medical Emergency or Accidental Injury(1) In order to be covered for services under this Section 516 the Member must notify the

Plan within twenty-four (24) hours after admission to a hospital or as soon as medically possible after admission where the Member is incapable of calling the Plan

(2) Outpatient follow-up services necessary for the continued treatment of a Medical Emergency or Accidental Injury are covered by the Memberrsquos Affiliated PhysicianPCP only unless specifically authorized in writing by the Planrsquos Medical Director or designee

(3) Consult Rider for application Co-pay

521 Language ServicesThe Plan provides an interpreter if the Member does not speak English and a sign language interpreter if the Member has a hearing impairment For assistance the Member must call the Plan at 313-871-2000 or 1-800-826-2862 or the TDDTTY line at 1-800-647-3777

522 Pain ManagementEvaluation and treatment of chronic andor acute pain is covered as specified in Plan medical policies

523 Hearing Aid(1) An Audiometric Examination is covered when performed by an Audiologist or Referral

Physician who has been authorized by the Plan to perform such an examination This

32

examination may also include a Hearing Aid Evaluation Test if deemed medically necessary by the Affiliated PhysicianPCP or Audiologist or Referral Physician (when approved by the Plan)

(2) Hearing Aids including Ear Molds are covered when prescribed by an Affiliated PhysicianPCP Audiologist or Referral Physician and approved by the Plan Hearing Aids of the following functional types are covered in-the-ear behind-the-ear (including air conduction and bone conduction types) and on-the-body Replacement parts repair and battery replacement are covered only when authorized by the Medical Director or hisher designee

LimitationsHearing Aid benefits are limited to one Hearing Aid per ear every three (3) years up to $600 per hearing aid Hearing Aids are limited to Affiliated Providers in the Total Health Care USA Network only

524 Durable Medical Equipment Prosthetics amp Orthotics(1) Durable Medical Equipment (DME) is equipment intended for repeated use in order to

serve a medical need is generally not useful to a person in the absence of Illness or Injury and is appropriate for use in the home Examples of covered DME are manual wheelchairs CPAP machines and glucose monitoring devices DME is covered exclusively from the Planrsquos DME provider

Coverage Limitationsbull NOTE Inhaler assist devices and some diabetic supplies such as syringes needles

lancets and blood glucose test stripes may be covered as a prescription drug benefit depending on where you obtain the supplies

bull Coverage is for standard DME only Equipment must be appropriate for home usebull Coverage is limited to one piece of same-use equipment The Plan may substitute one

type or brand of DME for another when the items are comparable for meeting your medical needs Wheelchair Coverage is generally limited to a manually operated standard wheelchair unless another model is Prior Approved according to our Medical Policies

bull DME may be rented purchased or repaired The decision to rent purchase repair or replace DME is made by the Plan We may limit replacement of DME to the expected life of the equipment

Non-Covered Servicesbull Equipment that is not conventionally used for the medical need for which it was

prescribedbull Equipment and devices solely for the convenience of you or your caregiverbull The purchase or rental of personal comfort items convenience items or household

equipment that have customary non-medical purposes such as protective beds chair lifts air purifiers water purifiers exercise equipment non-allergenic pillows mattresses or waterbeds spas tanning equipment and other similar equipment even if they are MedicallyClinically Necessary

bull Modifications to your home living area or motorized vehicles This includes equipment

33

and the cost of installation of equipment such as central or unit air conditioners escalators elevators swimming pools and car seats

bull Items designed for self-assistance safety communication assistance and other adaptive aids This includes but is not limited to reachers feeding dressing and bathroom aids augmentive communication devices car seats and protective beds

bull Non-standard DME unless we approve the non-standard equipment in advancebull All repairs and maintenance that result from misuse or abusebull Replacement of lost or stolen DMEbull Certain outpatient medical supplies that are consumable or disposable including but

not limited to gloves diapers adhesive bandages elastic bandages and gauzebull Durable Medical Equipment excludes any deluxe equipment and features as

attachments to such equipment which are not medically necessarybull Any medical supplies not medically necessary for the operation of Durable Medical

Equipment are excluded(2) Prosthetic and Orthotic Equipment and Devices (PampO) are covered when prescribed

by an Affiliated PhysicianPCP or by a Referral Physician (if approved by an Affiliated PhysicianPCP) authorized by the Planrsquos Medical Director or hisher designee Adjustments and replacements of PampO are covered in the following cases(a) Wear and tear(b) Changes in memberrsquos condition or(c) Change in size needed

Non-Covered Servicesbull All repairs and maintenance that result from misuse or abusebull Appliances that have been lost or stolenbull Prosthetic or orthotic devices that are not conventional not Medically Necessary

according to the criteria set forth in our medical policies or for the convenience of the Member or caregivers

bull Clothing necessary for prosthesis other than the approved initial purchase is excluded(3) Food Supplements and Formula

(a) Supplemental feedings administered via tube known as enteral feeding along with formulas intended for this type of feeding supplies equipment and accessories needed to administer this type of nutrition therapy

(b) Supplemental feedings administered via an IV known as parenteral nutrition along with associated nutrients supplies and equipment needed to administer this type of nutrition

Non-Covered Services(c) All other food formula and nutritional supplements except those intended for tube

feeding and nutrients necessary for IV feeding This includes but is not limited to infant formula protein or caloric boosting supplements vitamins Ensure Osmolyte and herbal preparations or supplements even if approved by the FDA

525 Skilled NursingSkilled nursing care including therapy and room and board in semi-private accommodations at a skilled nursing sub-acute or inpatient rehabilitation facility will be provided when

34

deemed medically necessary andor appropriate by an Affiliated PhysicianPCP or by a Referral Physician (if approved by an Affiliated PhysicianPCP when authorized by the Planrsquos Medical Director or hisher designee and under an approved treatment plan in advance Skilled Nursing Care is limited to forty-five (45) days per calendar year

Non-Covered Services Include(1) Admission to a skilled nursing sub-acute or inpatient rehabilitation facility if the necessary

care or therapies can be provided safely in a less intensive setting including the home or an Affiliated Providerrsquos office

(2) Care provided in a facility required to protect you against self-injurious behavior(3) Custodial Care even if you receive Skilled Nursing Services or therapies along with

Custodial Care(4) Leave of Absence Bed-hold charges incurred when you are on an overnight or weekend

pass during an inpatient stay(5) Residential Facility or Assisted Living Facility Care Non-skilled care received in a

residential facility or assisted living facility on a temporary or permanent basis is not covered Examples of such care include room and board health care aids and personal care designed to help you in activities of daily living or to keep you from continuing unhealthy activities

(6) Room charges that exceed the cost of a semi-private room when the room upgrade is requested by the Member and a semi-private room is available The Member must pay the facility those charges that exceed the cost of a semi-private room payable by the Plan

526 Tobacco Cessation Treatment(1) Smoking Cessation services provided by the Planrsquos Behavioral Health Provider(2) Tobacco Cessation prescription drug treatments are Covered according to the Approved

Drug List

527 Weight Loss Services for Morbid Obesity

Covered Servicesbull Weight loss management programs pre-approved by the Plan and provided exclusively

within the Total Health Care Network Contact Customer Service at (313) 871-2000 for more information

bull Certain surgical treatments and bariatric surgery when co-morbid health conditions exist and all reasonable non-surgical options have been tried Surgical treatment for weight loss must be prior approved by the Planrsquos Medical Director

Coverage Limitationsbull Surgical treatment of obesity is limited to once per lifetime unless Medically Necessary to

correct or reverse complications from a previous bariatric procedure

Non-Covered Servicesbull Weight loss services not specifically listed above under Covered Services This includes

but is not limited to food food supplements gastric balloons certain weight loss surgeries jaw wiring liposuction physical fitness or exercise programs diet supplements

35

ARTICLE VI EXCLUSIONS AND LIMITATIONS

601 All benefits and services not specifically described as Authorized Benefits and Services in this Certificate unless benefits and services are allowed under State or Federal law are excluded from coverage under this Certificate

602 Services for disabilities associated with military service to which the Member is legally entitled and for which facilities are reasonably available to the Member are not covered

603 Services for an occupational injury or disease for which services payment or reimbursement is available under any workerrsquos compensation or employerrsquos liability law are not covered

604 Care for conditions that federal state or local laws require be treated in a public health facility is not covered

605 Infertility treatment is not covered

606 Services ordered by a court of competent jurisdiction are not covered unless they are otherwise Authorized Benefits and Services

607 Services provided during police custody are not covered unless they are otherwise Authorized Benefits and Services

608 Services for mental illnesses disorders and disabilities that according to generally accepted professional standards are not amenable to treatment are not covered

609 Unless included in a Rider outpatient prescription or nonprescription drugs and diet supplements are not covered

610 Surgery and other services for cosmetic purposes as determined by the Planrsquos Medical Director or hisher designee are not covered

611 Dental services andor surgeries are not covered except in cases of multiple extractions or removal of unerupted teeth under general anesthesia where a concurrent medical condition exists

612 Medical surgical and other health care procedures determined by the Planrsquos Medical Director to be experimental (including research studies) are not covered Health services that are unusual infrequently provided and not necessary for the protection of individual health are not covered

613 Services that are deemed not Medically Necessary Unless stated below the Planrsquos Medical Director or designee will make the final determination of medical necessity(1) Services and supplies that the Plan determines are not Medically Necessary according to

medical and behavioral health policies established by the Plan with the input of Physicians not employed by the Plan or according to criteria developed by reputable external sources and adopted by the Plan

(2) Those services rendered by a Health Professional that do not require the technical skills of such a Provider

36

(3) Those services and supplies furnished mainly for the personal comfort or convenience of you anyone who cares for you or anyone who is part of your family

(4) Those services and supplies furnished to you as an inpatient on any day on which your physical or mental condition could safely and adequately be diagnosed or treated as an outpatient

(5) Any service or supply beyond those services sufficient to safely and adequately diagnose or treat your physical or mental condition and

(6) Additional or repeated services or treatments of no demonstrated additional benefit(7) NOTE If we exclude Coverage because a service or supply is not Medically Necessary

that decision is a determination about benefits and not a medical treatment determination or recommendation You with a Physician may choose to go ahead with the planned treatment at your own expense You have the option to Appeal our denial of your claim for Coverage as described in Section IV 407

614 Reversal of voluntary surgically induced sterilization is not covered

615 Services of private duty nurses are not covered unless they are authorized by the Planrsquos Medical Director or designee before the services are rendered

616 Custodial care domiciliary care or basic care in a residential institutional or other setting that is primarily for the purpose of meeting the Memberrsquos personal needs and which could be provided by persons without professional skills or training is not covered Examples of custodial care include assistance in bathing dressing eating walking getting in and out of bed and taking medicine

617 General housekeeping services and personal convenience items including but not limited to television and telephone services are not covered

618 Health care benefits and services rendered as a result of a motor vehicle accident are not covered to the extent there is coverage under any insurance policy

619 Services that constitute vocational rehabilitation or employment counseling or that are in connection with examinations for insurance employment screening are not covered except as they may be incidental to an annual health examination

620 If a Member requests inpatient accommodations that are more expensive than those provided in this Certificate the Member must pay the Hospital the difference between those charges incurred and those allowable and payable by the Plan

621 Unless included in a Rider elective abortions are not covered

622 Items or Services Furnished Ordered or Prescribed by any Provider included on the Office of Inspector Generalrsquos (OIG) List of Excluded IndividualsEntities or the Systems for Award Management These lists are available on the OIG website at wwwhhsgovoig or samgov

37

ARTICLE VII PRIOR APPROVALAUTHORIZATION REQUIREMENTS

Some services and supplies require Prior Approval by the Plan in order to be covered under this Plan The complete and detailed list of these services is available by calling the Customer Service Department at 313-871-2000 or online at wwwTHCmicom This list may change throughout the Contract Year as new technology and standards of care emerge Below are the general categories of services and supplies that require Prior Approval by the Plan

(1) All inpatient services with the exception of(a) Inpatient admissions as the result of a Medical Emergency(b) Inpatient Hospital admissions for a mother and her newborn up to forty-eight (48) hours

following a vaginal delivery and ninety-six (96) hours following a cesarean delivery(2) Behavioral Health and Substance Abuse Disorder inpatient and partial hospitalizations(3) Outpatient services as outlined on our website including but not limited to outpatient

surgeries(4) Referrals to Non-Affiliated Physicians and Providers(5) Prosthetic and orthotic charges over $200 and all shoe inserts(6) Implant DevicesStimulators(7) Genetic Testing(8) Home Health Care(9) Hospice(10) Diagnostic Imaging Examinations including but not limited to

(a) PET Scans (positron-emission tomography)(b) MRI (Magnetic Resonance Imaging)(c) CT Scans (computed tomography)(d) Nuclear Cardiology Studies

(11) Certain Injectable Drugs and Specialty Drugs (under the Medical Benefits)(12) Transplants and evaluations for Transplants(13) Clinical trials for cancer care or other life-threatening conditions or disease(14) Sterilization ndash Female or Male Vasectomy is covered only when performed in a physician

office or when performed in connection with another covered inpatient or outpatient surgery

(15) Additional items as outlined on our website

Non-Urgent Requests Contact the Plan as soon as an Affiliated Provider recommends a service or supplies that require Prior Approval In most cases the Plan will approve partially approve or deny a request for Prior Approval within fifteen (15) days of receipt In some cases the Plan may ask for additional information or additional time in which to make a determination Based on Plan approval or denial you and your Provider can decide if you want to go forward with the proposed services or obtain the supplies

Urgent Requests For urgent requests the Plan must respond within seventy-two (72) hours A request is considered urgent if delaying treatment would put your life in serious danger interfere with your full recovery or delay treatment for severe pain The Plan will send a letter to both the Member and the Affiliated Provider who ordered the services in the event that the service is denied coverage

38

If you obtain services that the Plan says are not covered or services in excess of what the Plan says is covered you are responsible for payment for those services If you want the Plan decision to be reconsidered you may contact us Refer to Section IV as to your right for Appeal

Reevaluation of Decision on Prior Approval At any time your Physician may ask us to re-evaluate a Prior Approval decision we have made

Retrospective Review It is important to get Prior Approval so you know ahead of time if the services or supplies you seek will be covered If the required Prior Approval is not obtained we may review the claim after you receive the services If we determine that the care received was Medically Necessary and provided by an Affiliated Provider the care will be covered If we determine that the care received was Medically Necessary and provided by a Non-Affiliated Provider or not your assigned Affiliated PhysicianPCP the care may be covered only if the necessary care was unavailable from an Affiliated Provider If we determine that the care received was not Medically Necessary or the care was provided by a Non-Affiliated Provider or a PCP other than your assigned PCP when it could have been provided by an Affiliated Provider or your assigned PCP the services will not be covered

ARTICLE VIII SUBROGATION

801 Subrogation means that the Plan will have the same right as a Member to recover expenses for treatment of an injury or illness for which another person or organization is legally liable To the extent the Plan provides services in such situations the Plan will be subrogated to the Memberrsquos right of recovery against any responsible person or organization including any other health plan or insurers on policies of insurance including those issued to and in the name of the Member

802 By acceptance of an identification card from the Plan the Member agrees as a condition to receiving Authorized Benefits and Services under this Certificate that the Member will make a good faith effort to pursue recovery from any liable person or organization and upon collection of any recoveries for any Authorized Benefits and Services provided by the Plan will reimburse the Plan The Plan shall have a lien for any Authorized Benefits and Services rendered on any such recoveries whether by judgment settlement compromise or reimbursement

803 Members shall take such action furnish such information and assistance and execute such assignments and other instruments as the Plan may request to facilitate enforcement of the rights of the Plan hereunder

804 A Member shall not compromise or settle a claim or take any action that would prejudice the rights and interests of the Plan without the Planrsquos prior written consent

805 Refusal or failure of a Member without good cause to cooperate with the Plan under this Article shall be grounds for termination of membership in the Plan and for recovery by the Plan from the Member for the value of services and benefits provided by the Plan

39

ARTICLE IX COORDINATION OF BENEFITS

901 The coordination of benefits (COB) provision applies when a person has health care coverage under more than one Plan A Plan includes group and non-group insurance contracts health maintenance contracts (HMO) or other forms of group or group-type coverage (whether insured or uninsured) medical care components of long-term care contracts medical benefits under group or individualized automobile contracts and Medicare of any other federal governmental plan as permitted by law The priority of responsibility under the coordinating insurance policies or certificates will be determined in the following manner as prescribed under Act No 64 of the Public Acts of 1984(1) The benefits of a policy or certificate that covers the person on whose expense the claim

is based other than as a Dependent shall be determined before the benefits of a policy or certificate which covers the person as a Dependent

(2) Except as otherwise provided in subsection (3) if two (2) policies or certificates cover a person on whose expenses the claim is based as a Dependent the benefits of the policy or certificate of the person whose birthday anniversary occurs earlier in the calendar year shall be determined before the benefits of the policy or certificate of the person whose birthday anniversary occurs later in the calendar year If the birthday anniversaries are identical the benefits of a policy or certificate that has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time However if either policy or certificate is lawfully issued in another state and does not have the coordination of benefits procedure regarding Dependents based on birthday anniversaries as provided in this subsection and as a result each policy or certificate determines its benefits after the other the coordination of benefits procedure set forth in the policy or certificate that does not have the coordination of benefits procedure based on birthday anniversaries shall determine the order of benefits

(3) In the case of a person for whom claim is made as a Dependent minor child benefits shall be determined according to the following(a) Except as provided in paragraph c below if the parents of the minor child are legally

separated or divorced and the parent with custody of the child has not remarried the benefits of the policy or certificate that covers the minor child as a Dependent or the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the non-custodial parent

(b) Except as provided in paragraph c below if the parents of the minor child are divorced and the parent with custody has remarried the benefits of a policy or certificate that covers the minor child as a Dependent of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent and the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the non-custodial parent

40

(c) If the parents of the minor child are divorced and the decree of divorce places financial responsibility for the medical dental or other health care expenses of the minor child upon either the custodial or the non-custodial parent the benefits of the policy or certificate that covers the minor child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other policy or certificate that covers the minor child as a Dependent

902 If Section 801 (1) (2) and (3) above do not establish an order of benefit determination the benefits of a policy or certificate in connection with a group disability benefit plan that group disability plan has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time subject to the following(1) The benefits of a policy or certificate covering the person on whose expenses the claim is

based as a laid-off or retired employee or a Dependent of a laid-off or retired employee shall be determined after the benefits of any other policy or certificate covering the person other than as a laid-off or retired employee or Dependent of a laid-off or retired employee

(2) Subsection (1) shall not apply if either policy or certificate is lawfully issued in another state and does not have a provision regarding laid-off or retired employees and as a result each policy or certificate determines its benefits after the other

903 Benefits under this Certificate shall not be reduced or otherwise limited because of the existence of another non-group contract that is issued as a hospital indemnity surgical indemnity specified disease or other policy of disability insurance as defined in Section 3400 of the Insurance Code of 1956 Act 218 of the Public Acts of 1956 being Section 5003400 of the Michigan Compiled Laws

904 Health care benefits and services rendered as a result of a motor vehicle accident are not covered to the extent there is coverage under any other policy

905 The Plan is not required to pay claims or coordinate benefits for services that are not provided or authorized by the Plan and that are not Authorized Benefits and Services under this Certificate

ARTICLE X CHANGES IN RATES CERTIFICATE OR STATUS OF MEMBERS

1001 The Plan will not make adjustments in the rate(s) used to determine Premiums nor in the terms andor conditions of this Certificate with less than thirty (30) days written notice to the Remitting Agent

1002 The Subscriber must notify the Plan in writing within thirty (30) days of any changes in the status of each Member as a result of divorce death birth legal adoption changes in legal residence of children changes in address change of telephone number andor entrance into or return from military service or when a Dependent has been employed by a company offering health benefits

41

ARTICLE XI TERMINATION OF GROUP COVERAGE

1101 The Certificate and the Group Operating Agreement shall continue in effect for one (1) year from the effective date and from year to year thereafter The Plan may terminate this Certificate and the Group Operating Agreement without notice if the Group fails to pay the Premium within the Grace Period

In the event the Premium is not paid within the Grace Period this Certificate terminates and all Authorized Benefits and Services cease retroactively as of 1159 pm on the due date unless otherwise expressly agreed upon by the Plan in writing In the event of termination the Plan reserves the right to recover from the Group the costs of services rendered to the Members during the period following the due date and to reject claims submitted by providers for services rendered during the period following the due date

ARTICLE XII TERMINATION OF A MEMBERrsquoS COVERAGE

1201 If this Certificate is terminated pursuant to Article X the Memberrsquos coverage shall terminate at the time specified in Article X without further action of the Plan

1202 If a Member ceases to meet the eligibility requirements of the Group Operating Agreement and this Certificate coverage shall terminate (subject to the conversion rights under Article XII) as follows(1) If the Subscriber ceases to be a member of the Group Authorized Benefits and Services

for the Subscriber and enrolled Dependents will be continued only until the end of the month for which Premiums have been paid without any further action by the Plan

(2) Upon the death of the Subscriber all Authorized Benefits and Services will be continued for enrolled Dependents only until the end of the month for which Premiums have been paid without any further action by the Plan

(3) In the event of divorce or legal separation of Subscriber and Spouse all Authorized Benefits and Services will be continued for the Spouse only until the end of the month for which Premiums have been paid without any further action by the Plan

(4) In the event a Member becomes a member of the Armed Services of the United States all Authorized Benefits and Services shall terminate as to such Member as of that date without any further action by the Plan

(5) Coverage shall terminate at the end of the month in which a Dependent attains the age of twenty-six (26) or becomes eligible for coverage from hisher employer

(6) In the event a Member transfers residence outside the Service Area Authorized Benefits and Services may be terminated

1203 The Plan may rescind a Memberrsquos coverage under this Certificate for intentional misrepresentation of a material fact on the Enrollment Application

1204 The Plan may terminate a Memberrsquos coverage for providing false or misleading information or withholding material information on any required plan form or in applying for or seeking any health care under the terms of this Certificate Termination of coverage is effective ten (10) days after notice of termination is given by the Plan

42

1205 The Plan may terminate a Memberrsquos coverage if that Member knowingly fails or refuses to furnish information requested by the Plan Termination of coverage is effective ten (10) days after notice of termination is given by the Plan

1206 The Plan may terminate a Memberrsquos coverage if the Member aids attempts to aid or knowingly permits any other person not a Member to obtain benefits or services from or through the Plan Termination of coverage is effective immediately

1207 The Plan may terminate a Memberrsquos coverage if the Member refuses or fails without good cause to cooperate with the Plan pursuant to Article VII

1208 Members may elect to terminate their coverage during Group Open Enrollment that occurs once a year or in the event that the Member ceases to meet the eligibility requirements as defined in this document or the Group Operating Agreement by giving written notice to the Plan and the Remitting Agent

1209 Benefits for any authorized inpatient admission to a Hospital or skilled nursing facility that began prior to the effective date of termination will be provided only until the date of termination

1210 The Plan may terminate a Memberrsquos coverage if that Member fails to report theft or loss of a Member ID card within the time required by Section 404 Termination of coverage is effective immediately

1211 The Plan may terminate the enrollment of a Member for the inability of the Member to establish a satisfactory relationship between the hisherself and an Affiliated PhysicianPCP including failure to comply with a prescribed treatment regimen after reasonable attempts at establishing a satisfactory relationship with not less than two (2) Affiliated PhysicianPCPs have proven unsuccessful This provision is subject to the Memberrsquos rights under the Planrsquos grievance procedure to determine whether such a situation exits Termination is effective thirty (30) days after notice of termination is given by the Plan

ARTICLE XIII CONTINUATION COVERAGE AND CONVERSION

1301 Continuation of Group Coverage Option(1) A Member may be entitled under the Consolidated Omnibus Budget Reconciliation

Act (COBRA) to continue hisher coverage under this Certificate by making periodic payments directly to hisher Group Subject to its terms and conditions and timely payment this Certificate shall be continued for such members for a maximum of eighteen (18) months from the date of termination of employment or thirty-six (36) months from the date of death divorce or loss of Dependent status or until the continuation of Coverage is no longer available through the Group

(2) Upon election to continue coverage for eighteen (18) months or thirty-six (36) months payment shall be made by the Member to the Remitting Agent who shall pay the Plan in advance at the rate and in accordance with the frequency schedule established by the Plan unless otherwise agreed to by the Plan in writing If the Premium is not received

43

within thirty (30) days of the due date this Certificate may terminate without notice If this Certificate is terminated the Plan reserves the right to recover from the Group the cost of services rendered during the period following the due date

(3) A Member who elects to receive continuing coverage for a maximum of eighteen (18) months or thirty-six (36) months as applicable may convert to an individual contract at the end of the eighteen (18) month or thirty-six (36) month period

1302 Conversion Option(1) A Member who loses eligibility for coverage under this Certificate as a Group Member

for other than hisher violation of this Certificate is entitled to convert this Certificate to an individual contract by making Application within thirty (30) days of receiving notification of the event which made the Member ineligible for Group coverage Evidence of good health will not be required by the Plan in order exercise this conversion option

(2) Individual coverage will be of the type currently being offered by Total Health Care USA and may not be identical to the health care benefits provided by this Group Certificate

(3) If a Member fails to make timely payment to the Plan the Memberrsquos coverage under the Individual contract will be subject to termination in accordance with the terms of the contract

ARTICLE XIV MEMBER RIGHTS amp RESPONSIBILITIES

As a Total Health Care USA Member you have the right tobull Receive prompt medical care appropriate for your condition including emergency care

if necessarybull Discuss all treatment options available to you regardless of Coverage limitations bull Receive information about the Plan our services our Providers and your rights and

responsibilitiesbull Collaborate with Physicians and Health Professionals to make informed decisions about

the care that you receivebull Be treated with respectbull Have your privacy protectedbull Have your medical and financial records maintained by the Plan kept confidential whether

in electronic or written form We will not disclose information about your medical records without your consent except as allowed by Law or in accordance with our Notice of Privacy

bull Be notified in a timely manner if we release information about you in response to a court order

bull Inspect your medical records and those of your minor dependents as allowed by state of federal law

bull Contact us to discuss concerns about the quality of care you have received from an Affiliated Provider

bull Register a complaint or file a Grievance with us or the Director of the Department of Insurance and Financial Services (DIFS) without retaliation if you experience a problem that remains unresolved

bull Initiate a legal proceeding without retaliation if you experience a problem with the Plan or our Affiliated Providers after you have exhausted the Grievance Process

44

As a Total Health Care USA Member you have the responsibility to

bull Read the Certificate of Coverage and accompanying Member materials

bull Understand and comply with the terms and conditions of your health benefits contained within this Certificate

bull Coordinate all medical services through your Affiliated PhysicianPCP except in the case of a Medical Emergency

bull Obtain Prior Authorization form the Plan as specified in this Certificate except in the case of a Medical Emergency

bull Comply with the limits of any approval of services

bull Use Participating Providers for all services and supplies not requiring Prior Approval

bull Pay Copayments Deductibles and Coinsurance as appropriate and at the time of service

bull Present your ID Card to the Provider before receiving a service

bull Notify the Plan promptly if your ID card is stolen and cooperate with the Plan to prevent the unauthorized use of your ID card

bull Follow instructions concerning your treatment plans and collaborate with Physicians and Health Professionals to make informed decisions about your care

ARTICLE XV PRESCRIPTION DRUG RIDER

This Rider to the Policy is issued to the Enrolling Group and provides Benefits for Prescription Drug Products

NOTE The Coordination of Benefits provision in the Certificate in Section 7 Coordination of Benefits applies to Prescription Drug Products covered through this Rider Benefits for Prescription Drug Products will be coordinated with those of any other health plan in the same manner as Benefits for Covered Health Services described in the Certificate

Coverage provided is based on the Plan Approved Drug List with required dispensing from an Affiliated Pharmacy or Plan Mail Order Pharmacy

The Pharmacy amp Therapeutics Management Committee (PampT) authorizes tier placement changes The PampT makes the final classification of an FDA-approved Prescription Drug Product to a certain tier by considering a number of factors including but not limited to clinical and economic factors Clinical factors may include but are not limited to evaluations of the place in therapy relative safety or relative efficacy of the Prescription Drug Product as well as whether certain supply limits or prior authorization requirements should apply Economic factors may include but are not limited to the Prescription Drug Productrsquos acquisition cost including but not limited to available rebates and assessments on the cost effectiveness of the Prescription Drug Product

Some Prescription Drug Products are more cost effective for specific indications as compared to others therefore a Prescription Drug Product may be listed on multiple tiers according to the indication for which the Prescription Drug Product was prescribed or according to whether it was prescribed by a Specialist Physician

We may periodically change the placement of a Prescription Drug Product among the tiers These changes generally will occur quarterly These changes may occur without prior notice to you

When considering a Prescription Drug Product for tier placement the PampT reviews clinical and economic factors regarding Covered Persons as a general population Whether a particular Prescription Drug Product is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician

NOTE The tier status of a Prescription Drug Product may change periodically based on the process described above As a result of such changes you may be required to pay more or less for that Prescription Drug Product Please refer to the Approved Drug Lists available at wwwTHCmicom or call Customer Service for the most up-to-date information

The Plan requires that you use an Affiliated Pharmacy for prescription drugs including but not limited to Specialty Prescription Drugs and mail orders to obtain benefits within the THC Network

Benefits for drugs on the Approved Drug List are available when the drug meets the definition of Authorized Benefits and Services (see Definition 210) or the Member is part of an Approved Clinical Trial (see Definition 208)

Upon purchase of a rider members will receive a specific Schedule of Out-of-Pocket Expenses related to pharmacy co-pays coinsurance and deductibles


3011 West Grand Blvd

Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom

Table of Contents

NONDISCRIMINATION NOTICE i

ARTICLE I TOTAL HEALTH CARE USA INC 1

ARTICLE II DEFINITIONS 1ndash6

ARTICLE III ENROLLMENT EFFECTIVE DATE OF COVERAGE PREMIUMS 6ndash8

ARTICLE IV GENERAL CONDITIONS 8ndash14

ARTICLE V COVERED BENEFITS AND SERVICES 14ndash34

ARTICLE VI EXCLUSIONS AND LIMITATIONS 35ndash36

ARTICLE VII PRIOR APPROVALAUTHORIZATION REQUIREMENTS 37ndash38

ARTICLE VIII SUBROGATION 38

ARTICLE IX COORDINATION OF BENEFITS 39ndash40

ARTICLE X CHANGES IN RATES CERTIFICATE OR STATUS OF MEMBERS 40

ARTICLE XI TERMINATION OF GROUP COVERAGE 41

ARTICLE XII TERMINATION OF A MEMBERrsquoS COVERAGE 41ndash42

ARTICLE XIII CONTINUATION COVERAGE AND CONVERSION 42ndash43

ARTICLE XIV MEMBERS RIGHTS amp RESPONSIBILITIES 43ndash44

ARTICLE XV PRESCRIPTION DRUG RIDER 44ndash45




Total Health Care









(800) 368-1019 (800) 537-7697 (TDD)


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করzwjন ১ (800) 826-2862 (TTY 711)








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Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom



Total Health Care









(800) 368-1019 (800) 537-7697 (TDD)


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করzwjন ১ (800) 826-2862 (TTY 711)








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Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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(313) 871-2000

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom









Suite 1600

Detroit MI 48202

(313) 871-2000

wwwTHCmicom

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